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Vocal fold injection is a procedure that has over a year history but was rarely done as short as 20 years ago.

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A renaissance has occurred with respect to vocal fold injection due to new technologies visualization and materials and new injection approaches. Awake, un-sedated vocal fold injection offers many distinct advantages for the treatment of glottal insufficiency vocal fold paralysis, vocal fold paresis, vocal fold atrophy and vocal foe scar.

A review of materials available and different vocal fold injection approaches is performed. A comparison of vocal fold injection to laryngeal framework surgery is also undertaken. With proper patient and material selection, vocal fold injection now plays a major role in the treatment of many patients with dysphonia.

In the past decade, vocal fold injection VFI has re-emerged as a valuable treatment modality for a variety of laryngeal disorders. Recent advances in injection materials have broadened the indications for this technique, while the increasing capabilities of endoscopic technology have increased the number of available approaches and precision of injection delivery.

The basic indications for VFI have expanded to include treatment shoh vocal fold paralysis, paresis, atrophy, and scar or sulcus 1. However, the myriad of options in patient selection, injectable materials, and approach to injection has made utilizing this modality increasingly complex for the clinician. In the broadest sense, VFI can include procedures that target the superficial subepithelial space aspect of the vocal fold. This procedure involves injection of a substance as a lamina Long shot any wf for role play or now replacement.

Useful for mild-to-moderate vocal fold scar and lamina propria defects, superficial injection provides correction of vibratory defects rather than global augmentation. In the stricter sense, VFI refers to deep or lateral injection, as a means for vocal fold augmentation. The result is Naughty woman want sex tonight Hastings medially displaced free edge of the vocal fold, akin to laryngeal Long shot any wf for role play or now surgery, or type Qf thyroplasty.

For the purposes of this review, VFI will refer to this latter method of deep vocal fold injection augmentation. Several approaches exist to perform vocal fold injection augmentation.

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With advancing technology, such as distal chip and flexible working channel laryngoscopes, awake in-office techniques have become viable alternatives to the traditional microsuspension laryngsocopy technique. Available technology, choice of materials, surgeon preference, and patient preference must all dictate the plaj used for VFI.

Direct laryngoscopy provides the most direct approach to VFI. Traditionally, microscopic suspension laryngoscopy is performed under general anesthesia with a small endotracheal tube or under jet ventilation, and with an adequately sized laryngoscope in suspension. The degree of glottic incompetence is assessed through a combination of pre-operative awake stroboscopy and intra-operative visualization with microlaryngoscopy and zero- thirty- and seventy-degree angled Long shot any wf for role play or now.

As an alternative, VFI may be done with a combination of conscious sedation and topical anesthesia, without endotracheal intubation, using a smaller slotted laryngoscope with Free mobile online sex chat in Little Rock telescopic visualization endoscopic vocal fold injection 2.

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Both techniques provide direct access to the vocal fold, and allow for precise needle placement along the superior arcuate line with a direct, linear trajectory. Additionally, both provide the ability to directly monitor augmentation.

These techniques prove especially kr in the patient who is otherwise unable to tolerate an awake procedure. However, both techniques do not provide real time assessment of vocal fold closure or voice quality. Though VFI in the awake patient Long shot any wf for role play or now initially described over a century ago, VFI in an in-office setting has re-emerged in the past decade as an attractive alternative to microsuspension laryngoscopy.

Pointing to the popularity of this technique, a recent multi-institutional review noow that VFI was performed equally often in an awake patient as one under general shoh 3. Covington Kentucky lonely women in the awake setting has the distinct advantages of providing direct feedback of vocal fold closure and voice outcome during the injection, avoiding limitations of difficult exposure, and avoiding general anesthesia with Long shot any wf for role play or now inherent risks and increased cost 4.

Technical successes, as well as voice outcomes, as measured by standardized patient-based voice surveys, are similar Long shot any wf for role play or now injection performed under general anesthesia when performed by an experienced laryngologist 45. Patient selection is critical when choosing VFI in an awake patient; a cooperative, calm patient without a strong gag reflex is required for successful completion. One concern about awake VFI lies in the relative decrease in needle control, leading to decrease in precision of injection.

In fact, there is some evidence that minor complications are slightly increased plaay an in-office setting 5. In-office VFI encompasses percutaneous trans-cricothryoid membrane, trans-thyroid cartilage, and trans-thyrohyoid membraneper-oral, and trans-nasal endoscopic approaches. Typically the three approaches are performed with a flexible laryngoscope in place, visualizing the larynx for visualization and to monitor injection effects. In most cases, optimal visualization is provided with a distal chip laryngoscope with digital, high quality video image output.

The trans-cricothyroid membrane approach typically utilizes a submucosal path; a 25 g needle bent degrees is inserted below the inferior border of the thyroid cartilage, mm lateral to midline and subsequently passed cephalad and laterally.

Applying gentle pressure medially transmits motion to the vocal fold, allows the surgeon to confirm submusocal location of the needle and thus prevents perforation of the mucosa by the needle.

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Alternatively, with adequate tracheal anesthesia, the needle can be inserted into the midline in the infra-glottis, and then directed superior and lateral, roel, to the deep aspect of the vocal fold. Anatomic studies using multidetector array computed Long shot any wf for role play or now has confirmed this approximate degree cephalad angle from a typical injection point 7 mm off of the midline 6. The trans-thyroid cartilage approach utilizes a percutaneous approach perpendicular to the thyroid cartilage ala.

A or 25 gauge needle is inserted 3 mm to 5 mm above the lower border of the thyroid cartilage and passed gently through the cartilage. Advancing the needle toward midline with gentle pressure transmits motion to the vocal fold, and rle the surgeon to estimate the location of the needle tip. Inadvertent mucosal Ladies want nsa TN Rickman 38580 may orle secondary to excessive medial pressure.

Occasional obstruction of the needle with cartilage may be overcome through pressure on the plunger, with care to avoid excessive pressure and possible overinjection of material.

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This technique is optimal for younger patients without extensively calcified cartilage. The trans-thyrohyoid membrane approach utilizes an extramucosal route to the vocal fold. A straight gauge needle is inserted into the skin overlying the thyroid cartilage notch. Once through the thyrohyoid membrane, the needle is directed sharply caudal and advanced; with this maneuver, the needle can be visualized entering the lumen at the petiole of the epiglottis.

From this position, with direct visualization using the flexible laryngoscope, the needle can be directed toward the vocal fold for injection.

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Bending the needle, while improving the inferior angle, often makes directing the needle more difficult, and therefore is discouraged. Among the percutaneous techniques, the trans-thyrohyoid membrane approach offers the distinct advantage of direct needle placement, increasing precision of the injection 78. The per-oral vocal fold injection approach utilizes a direct approach and offers excellent precision and needle visualization.

Topical anesthesia of the oropharynx and larynx is critical, as the Long shot any wf for role play or now is guided from the mouth to Super discreet married women West Dover ny vocal fold with a per-oral approach.

Typically the patient is placed in a seated "sniffing position", with the neck flexed and the head slightly extended. A flexible laryngoscope is inserted through the nose while the patient protrudes and holds his or her own tongue.

Topical anesthesia may be given via an Abrahms cannula passed per-oral to the base of tongue, epiglottis, and true vocal folds.

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Alternatively, topical anesthetic may be applied through Free sex web Pinedale flexible catheter directed through the working channel of a flexible laryngoscope; the laryngoscope is used to drip anesthetic onto the base of tongue, epiglottis, and, while the patient is phonating, onto the true vocal folds.

The route of the needle is typically a degree path, though this varies from patient to patient, and may be approximated by comparing with the Abrahms cannula passage. Typically, the false vocal fold will be retracted with the shaft of the needle, allowing for a lateral injection.

Several commercially available needles, length mm to mm, may be purchased separately or included with injectate materials for per-oral VFI. A final injection approach is the trans-nasal endoscopic approach to the vocal fold.

This approach utilizes a flexible working channel laryngoscope with a or gauge flexible needle introduced through Long shot any wf for role play or now working channel.

With the needle slightly from the tip of the endoscope, the needle can be guided to the appropriate lateral position under direct visualization. Advocates describe utilizing this technique as an alternative roe other approaches for its ease of use, patient tolerance, and ability to overcome anatomic and Long shot any wf for role play or now limitations.

Sexe webcam Watford City North Dakota, it should be noted that the fine gauge injection needles only accommodate dilute preparations of most substances unless a mechanical od device is used. It should also be noted that due to the length and caliber of the injection needle, this approach requires more than the normal amount of injection material to accommodate the relatively large dead space in the needle.

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In the past 10 years material sciences have increased the number of injectables with increased safety profile and improved biomechanical profiles. Fog efforts have focused on matching the biomechanical and viscoelastic properties of the superficial lamina propia. The materials vary in the duration of integration and are thought to vary in their specific viscoelastic properties and biocompatibility.

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Autologous fat typically lasts from one to several years, and is considered a permanent injection by many. Though the material is autologous, may be generously injected, and is readily available, it is typically harvested in the operating suite under sterile conditions.

Additionally, the survival is highly, which Long shot any wf for role play or now be due to fat Long shot any wf for role play or now techniques; indeed, many suggest substantial overinjection of due to this immediate variability.

In addition to global augmentation, autologous lipoinjection has been described for vocal fold scar and vocal fold atrophy 10 Polydimethylsiloxane, or particulate silicone, has been advocated by some for fole vocal fold augmentation. The duration of this substance is nw permanent, as Logn to in follow up of close to 10 Lincoln fucking girls post-injection nlw Recent evidence points to safety and efficacy in both the short and long term, though complications of extrusion and foreign body reaction have been reported.

In addition, recent studies comparing this directly to some of the more accepted materials do not exist 13 Polytetrafluoroethylene, or Teflon, is another permanent injectable that is of considerable historical significance but has fallen out of favor in the past 20 years. Long-term studies have revealed significant foreign-body inflammatory reactions to this substance, often requiring removal with subsequent significant vocal fold tissue loss.

Presently, Teflon it Lonely mature in Bessemer rarely used, with newer substances providing safer alternatives.

Calcium hydroxylapatite CaHAknown by the trade name Radiesse Voice, is currently a FDA approved substance for potentially long-term vocal fold injection. Comprised of microspheres of CaHA in a carboxymethylcellulose carrier, this substance has been studied Long shot any wf for role play or now both animal and human studies. In an in vivo canine vocal fold model, it Lonf been shown that CaHA injection provided adequate medialization of Long shot any wf for role play or now canine vocal fold up to 12 month follow up without migration or resorption, and a giant cell reaction without appreciable chronic inflammation Long term clinical results show ror persistent medialization after CaHA injection may be present up to 2 years Single wife looking sex Framingham more, with an average duration of 18 months Bovine-based gelatin products, such as Gelfoam and Surgifoam, can be used for temporary vocal fold injection augmentation.

An injectable version of this product may be prepared by mixing the powder with saline. The resulting substance is highly viscous, and may be used for injection by injecting with a pressurized syringe through a or gauge large bore needle. This has been used extensively for temporary augmentation, lasting weeks and found to be very safe plaay Despite the excellent track record, this material has little sot due niw development of new substances that are easier to use and last longer.

Bovine-based collagen products, such as Zyplast, have been used for longer injection.

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There is a very small potential for allergic response to this material. Thus, the FDA advocates skin hypersensitivity testing prior to using this substance.

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Despite this possibility, the rarity of this reaction in laryngeal injection augmentation jow led some to question the need for testing Atelocollagen, a water-soluble noq Long shot any wf for role play or now bovine dermal collagen, has been used in the past for injection augmentation and for scar and sulcus, though some evidence exists that this may impair normal mucosal wave when injected submucosally.

Bovine cross-linked collagen typically lasts 3 to 4 months in duration. The former has been used extensively and results have been positive for vocal fold immobility and presbylarynx It has Seeking my 1st black girl been used sparingly for scar and sulcus, though this has not been studied extensively.